Current practice guidelines recommend video assisted thoracoscopic lung biopsy (VATSLB) for patients with interstitial lung diseases (ILDs) who do not have diagnostic CT scans. However, VATSLB in this population carries risk. The reported incidence of death after biopsy in patients with idiopathic pulmonary fibrosis (IPF) is up to 17%. We examined the morbidity and mortality associated with VATSLB in a group of outpatients with undefined ILD.
A retrospective cohort study of 68 outpatients referred for VATSLB of undefined ILD over a ten-year period. Information on post-operative mortality, prolonged air leaks (≥ 4 days or readmission for pneumothorax), pneumonias, worsening oxygenation, and re-admissions was abstracted from charts to calculate the incidence of these outcomes.
Average age was 57.9 years (range 38-84). The median length of stay was 2 (range 1-43) days and the median duration of chest tube therapy was 1 (range 1-11) day. Incidence of outcomes (95% CI): post-operative mortality 4.4% (3 of 68 patients) (0.9%-12.4%), prolonged air leak 11.8% (5.2%-21.9%), post-operative pneumonia 2.9% (0.4%-10.2%), worsening oxygenation 14.8% (6.6%-27.1%), readmission within one month 9.0% (3.4%-18.5%). Subsequent pathologic diagnoses included usual interstitial pneumonitis (UIP) (34%), non-specific interstitial pneumonitis (6%), desquamative interstitial pneumonitis/ respiratory bronchiolitis associated interstitial lung disease (4%), chronic hypersensitivity (8%), sarcoidosis (9%), honeycomb lung (9%), normal (3%), acute interstitial pneumonitis (2%), bronchiolitis (2%), emphysema (2%), and unclassifiable (22%). All three subjects who died had UIP. These patients were intubated for hypoxemic respiratory failure on post-operative days 2-8. Each had pulmonary embolus and congestive heart failure (CHF) excluded with appropriate clinical testing, and was treated with antibiotics and high dose steroids. One other subject was re-intubated post-operatively; she responded to diuresis for newly identified CHF.
VATSLB for outpatient subjects with undefined ILD is associated with appreciable surgical mortality/morbidity. The risks may be greatest in those who are subsequently diagnosed with IPF.
Further investigation is needed to better define both the exact incidence of these outcomes and risk factors for their development.
Mary Kreider, None.